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Coronary disease & ACSSecondary analysis

Invasive vs Conservative Management of Patients With Chronic Total Occlusion

J Am Coll CardiolPublished

  • Secondary analysis of the ISCHEMIA randomised trial
  • subgroup analysis (coronary computed tomographic angiography (CCTA)-determined chronic total occlusion (CTO))
  • intention-to-treat
  • inverse probability weighting (secondary analyses)
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Authors' conclusion

In the ISCHEMIA trial, the risks and benefits of INV compared with CON were similar among patients with and without CCTA-determined CTO (more frequent procedural MI, less frequent spontaneous MI, and significantly improved angina and dyspnea-related quality of life). In an observational comparison, successful CTO REV was associated with a high probability of lower CV death or MI (driven by lower MI) compared with CON.

Study context

Population
ISCHEMIA participants with CCTA evaluated for CTO by the core laboratorywith ≥1 CTO, of 3,113 CCTA-evaluable
Participants
1,470 participants
Comparison
INV vs CON
  • INVn = 752
  • CONn = 718reference
Primary endpoint
Outcomes in those randomized to INV vs CON (ITT); endpoint not further named as primary

Primary result

CV death or MI (CTO subgroup) · 5 years

Difference

−3.5%

95% CI −7.8% to 0.8%

INV vs CON
difference −3.5% (95% CI −7.8% to 0.8%)

As reported in the abstract

Further findings

Outcomedifference (95% CI)
Spontaneous MI (CTO subgroup) · 5 years−6.3% (−9.7% to −3.2%)
OutcomeEstimate
Quality of life with successful CTO REV — CTO REV vs CON · angina-related quality of life · significantly improvedmean difference 4.6 points
Quality of life with successful CTO REV — CTO REV vs CON · Rose Dyspnea Scale score (rescaled) · significantly improvedmean difference 5.3 points
Quality of life with successful CTO REV — CTO REV vs CON · EQ-5D visual analog scale score · significantly improveddifference 4.6 points

Successful CTO revascularization (REV) (modeled across INV) vs CON: Cardiovascular (CV) death or myocardial infarction (MI), MI, spontaneous MI, unstable angina, HF

High probability of any lower rate, counterbalanced by higher procedural MI
>90%
  • inverse probability weighting; observational comparison

Safety

Outcomedifference (95% CI)
Procedural MI (CTO subgroup) · 5 years · more procedural MIs with INV2.5% (1.0%–4.0%)

Original publication

Invasive vs Conservative Management of Patients With Chronic Total Occlusion. J Am Coll Cardiol. Published 1 April 2025. doi:10.1016/j.jacc.2025.01.029
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Summarised from the published abstract; every number is checked against it